(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "The topical uses of water in surgery : presented to the American Medical Association at its session of May, 1852"

m i) : 



THE 



TOPICAL USES 



WATER IN SURGERY. 



BY 



CHARLES A. POPE, M.D. 



OF ST. LOUIS, MISSOl RJ. 



PRESENTED TO THE AMERICAN MKDICAL ASSOCIATION, 
AT ITS SESSION OF MAY, 1852. 



PHILADELPHIA: 
T. K. AND P. G>. COLLINS, PRINTERS, 

1852. 



THE 



TOPICAL USES 



WATER IN SURGERY. 



BY 

CHARLES A. POPE, M.D., 



/ 



OF ST. LOUIS, MISSOURI. 



PRESENTED TO THE AMERICAN MEDICAL ASSOCIATION. 
AT ITS SESSION OF MAY, 1852. 






PHILADELPHIA: 
T. K. AND P. G. COLLINS, PRINTERS. 

1852. 



THE TOPICAL USES 

OF 

WATEE IN SURGERY 



The great importance of water is sufficiently evinced by the fact 
that the ancients ranked it among the four elements, of which they 
supposed all matter to consist. This arose less, perhaps, from its 
chemical composition, than from the extensive part it plays in the 
economy of nature. The three kingdoms, indeed, claim its presence 
in variable quantities ; whilst it is absolutely essential to them all. 
Its action, being both chemical and mechanical, although gradual, is 
yet one of the most potent in the accomplishment of the changes 
which through long ages have been, and still are, in progress on the 
surface of the globe. 

But of these, as well as its universal diffusion — its different states — 
its innumerable and varied uses — its importance to the organism and 
to life, and its application in medicine generally, it is not our purpose 
to speak. To treat even of all the questions more immediately con- 
nected with our subject would easily fill a volume, and tax beyond 
practical utility the patience of the Association. 

We are to notice simply the local external effects of water in the 
department of surgery ; nor even here will we more than allude to its 
being often required in the ordinary cleansing and dressing of wounds, 
ulcers, etc., and to its constituting a frequent, and sometimes essential 
menstruum for the application of many remedies, whose beneficial 
effects are enhanced, if they do not even result as much from the 
water itself, as from the substances which it holds in solution. Instead 
of poultices and ointments, fomentations and lotions are greatly pre- 
ferable, as they combine all the advantages without the ill effects of 
the former. 

It is known that the use of water in surgery dates from the remotest 
antiquity ; instinct alone would have dictated a resort to it, as the 
most natural agent for the mitigation of pain. Its history shows 
that scarcely any remedy has been the subject of greater reverses of 



4 WATER — ITS TOPICAL USES IN SURGERY. 

favour and neglect from its first to its latest employment. Amid such 
mutation of opinion, of exaggerated eulogy on the one hand, and 
unmerited obloquy on the other, it will be our endeavour to ascertain, 
if possible, its real value ; to point out its therapeutic philosophy ; 
and to indicate the classes of injury and disease in which it seems 
more especially applicable. Happy, indeed, should we succeed in 
any degree to elicit the attention of the members, and induce its more 
general employment by the profession of our country. 

If we reflect for a moment on the vast influence for good or evil, 
of the local management of external lesions, as well as on their fre- 
quent daily and even hourly occurrence ; how, on the one hand, those 
which are in themselves grave may, by care and skill, be conducted 
to a successful issue ; and, on the other, those which are simple and 
apparently free from danger may, by ignorance or neglect, ultimately 
involve mutilation or death, the question, Which is the best mode of 
treatment ? strikes us, at once, as one of momentous importance. We 
have not the vain hope that water, or any other single substance, will 
suit all the varying phases of such disasters, or prove a universal 
surgical panacea; still, should it be found, under philosophical guid- 
ance, to answer most, or even some of the indications presented in 
their management, the subject were well worthy of a candid investi- 
gation. That in numerous instances it is capable of answering even 
our highest anticipations, will, we hope, abundantly appear. Em- 
ployed either warm or cold, in its solid, liquid, or vaporous state, 
simple or medicated, continuously or interruptedly, it were, perhaps, 
not difficult to show that water fulfils a majority, at least, of the indi- 
cations presented in the topical treatment of external lesions. 

In the remarks offered to the Association, it will be our chief object 
to direct attention to what we consider the most important points 
connected with the subject, viz : the modus operandi of water, when 
topically applied, and the therapeutical indications rationally based 
thereon. The history of its use in surgery, although of great interest, 
as well as the various modes of its application, must be very briefly 
noticed. Of these modes of local application we have affusion, fo- 
mentation, irrigation, lotion, immersion, injection, douche, etc. They 
may, perhaps, be reduced to three heads : water-dressing, irrigation, 
and immersion. The effects of water will vary according to its 
temperature, duration, and mode of contact, so that all these different 
methods are useful in their places. It belongs, therefore, to the tact 
and judgment of the surgeon to select that best adapted to the stage 
and circumstances of the case, and for the production of the desired 



WATER — ITS TOPICAL USES IN SURGERY. 5 

effect. For the details of the various modes of application, we beg 
to refer to the many memoirs on the subject, and especially to 
the thesis of Amussat the younger, whose excellent essay on the 
history and modes of application of water in surgery has, for the 
benefit of the American profession, been admirably translated by 
Prof. Frank H. Hamilton, of Buffalo. We also take pleasure in re- 
ferring here to a small, though valuable work, entitled Water versus 
Hydropathy, or an Essay on Water and its True Relations to Medicine, 
by Henry Hartshorne, M. D., of Philadelphia. A short chapter is 
devoted to the uses of water in surgery, but the main object of the 
author was to " prove by instance and citation, for which no very la- 
borious degree of research is necessary, how largely the profession 
have made use of that remedial element, the asserted nezv employ- 
ment of which, in one mode only of its protean applications, is the 
boast and support of a set of medical pretenders." 

On account of its simplicity and general accessibility, water 
must undoubtedly have been employed from the earliest ages of the 
world in the treatment of external lesions. Instances of its use 
occur both in Homer and in the Bible ; but it was reserved for Hip- 
pocrates to methodize its application. This great man seems to have 
fully comprehended its action and value. Indeed, but little has 
been really added to our knowledge on the subject since his time ; 
points which he broached having simply been developed, and the 
modes of applying water been regulated and extended. In his book, 
De Ilumidis, are found numerous ideas which have been generally 
supposed to belong to more modern times. Celsus and Galen also 
employed water in many surgical affections ; but the simplicity and 
good sense of such an example were soon forgotten amid the poly- 
pharmacy and pompous vulnerary display of their less skilful 
followers. For many centuries these continued in vogue, and, in 
accordance with the superstitious spirit of later times, disputes arose 
as to which was the better vulnerary, simple or blessed water ; every 
surgeon supposing that he possessed the true panacea. Among the 
miracles wrought by more vaunted and complex remedies, simple 
water met with but little notice; for, although employed, it was mixed 
with various ingredients, and accompanied with some absurd form of 
incantation, to which all its good effects were ascribed. In the sixteenth 
century, the great Pare', his pot of boiling oil having run out, learned 
by accident the surgical value of water : nor did he hesitate to 
acknowledge its successful employment by a noted empiric. He 
imitated the practice of Maitre Doublet, but saw, however, that its 



6 "WATER — ITS TOPICAL USES IN SURGERY. 

virtues were not attributable to "mysterious words and unchristian 
ceremonies, but to the simple clear water." Such was the spirit of 
the age, and the force of example, that he had long refused, on 
account of religious scruples, and its supposed supernatural effects, 
to employ water in the dressing of wounds. Even after Pare', the 
same strife as to the relative merits of simple and blessed water 
continued, until it was fortunately and forever settled by the chan- 
cellor of the University of Montpellier. 

Towards the beginning of the eighteenth century, Lamorier 
endeavoured to extend the employment of water, contending that 
there were few wounds which could not be healed by this treatment, 
more promptly and satisfactorily than by any other means. But it 
is to Lombard, a French military surgeon, that the modern revival 
of the practice is especially due. He established more precise rules 
for the use of water than any of his predecessors, in a work pub- 
lished in 1786, at the instance of Baron Percy. In an admirable 
article on this subject by the latter, in the Dictionnaire des Sciences 
Medicales, is to be found much historical and useful information, so 
largely drawn upon by succeeding copyists. Such were the convic- 
tions of Percy of the utility of water, that he declares, if deprived 
of its use, he would relinquish military surgery. 

It were an interesting task, did it comport with the objects of a 
Report, to notice the labours of those who, at different epochs, and 
often amid contumely and ridicule, have contributed to rescue water 
from neglect, and to extend its use in surgery. We must, however, 
content ourselves with the names of those already mentioned, and 
enumerate such only of the moderns as have been foremost in their 
advocacy of water dressings. Of the dead were Danter of Berlin, 
Kern of Vienna, Baron Larrey, who used the waters of the Nile, 
Breschet, Liston, Dieffenbach, M'Cartney, Walther, Josse, and Be*- 
rard. Among the living, are Cloquet, Jaeger, Chelius, Guthrie, Graefe, 
Miller, Langenbeck, Stromeyer, and, perhaps the most enthusiastic 
admirer of the practice, M. Baudens, the distinguished French mili- 
tary surgeon at the Val de Grace. He employs ice to a great extent, 
and contends for its superiority as a topical application. 

Notwithstanding the vaunted and even acknowledged beneficial 
effects of water, and its frequent employment, as we have seen, by 
the ancients, in almost all external affections, its use even now is far 
from being general. In the hospitals of Germany, it is perhaps more 
extensively used than in those of France or Great Britain. In the 
hospitals of this country, also, with a few exceptions, the old methods 



WATER — ITS TOPICAL USES IN SURGERY. 7 

of poultices, ointments, and dry dressings (lint compresses and 
bandages), still find wider favour than the more simple and cleanly 
water applications. In private practice, both on this and the older 
Continent, the advocates of the latter are perhaps more numerous, 
and water-dressings are in more frequent requisition. 

The mode of action of water is an important inquiry. But this 
will vary according as it is applied, cold, or warm, or hot, interrupt- 
edly or continuously, to the whole or a part of the body. No gene- 
ralities on its modus operandi can, therefore, well be given, so that 
we shall proceed to consider its effects according to its temperature, 
duration, and mode of contact. It will also be more clear and satis- 
factory to indicate, under each head, the diseases and conditions in 
which its use is deemed advisable. 

I. Cold Water from 35° to 55° Fahr. — Its effects will differ 
according as applied in an interrupted or in a continued manner. 

If its application be occasional or interrupted (intermittent irriga- 
tion of Bdrard), there is an immediate diminution of the temperature 
of the part, and a contraction of its capillaries, with a retardation 
of their circulation. The skin shrinks, becomes pale and cool, whilst 
the cutaneous secretion is impaired, or altogether suspended. There 
is also a diminution in the size of the part, the blood being repelled 
to the more internal organs. It is upon this principle that frequently 
heart disease occurs in a too long continued use of the cold bath. 
These phenomena continue whilst the application lasts, and gradually 
extend to the subjacent structures. If the contact be but slightly 
prolonged, reaction ensues. The blood driven with force by the 
deeper vessels, again dilates the capillaries, which yield " like a 
spring that has been bent." They are even increased in caliber, 
and are traversed in a given time by a greater number of blood- 
globules. Redness of the skin, with elevation of its temperature, 
and an increased size of the part, and sometimes augmented secre- 
tion, result from the more rapid circulation. A familiar example of 
this reaction is afforded by washing one's hands in winter with snow. 
Sometimes the reaction is excessive, reaching the true inflammatory 
state, with its highest result, mortification, as we see in cases of 
frost-bite. 

When thus used, water is therefore an indirect excitant of no 
inconsiderable power, and we perceive at once the therapeutical 
advantage which may be derived from it, in imparting tone to 



8 WATER — ITS TOPICAL USES IN SURGERY. 

weakened parts, and stimulating actions useful to the exercise of 
important functions. 

It follows, therefore, that the interrupted application (occasional 
showerings or immersion) of cold water will be useful. 

1. In frost-bite of the first degree. In these cases, frequent 
frictions with cold water, snow, or ice, are highly successful, as 
attested by the observation and experience of all ages. The circu- 
lation is thereby gradually restored to its proper equilibrium, and 
undue or too rapid reaction (inflammation with probable loss of sub- 
stance) is effectually prevented. 

2. As a hemostatic. In minor hemorrhages, arterial, venous, or 
capillary, cold water,' applied with a sponge, or poured on the part, 
constricts the vessels and thus affords a mechanical obstruction to the 
bleeding orifices. In hemorrhages not admitting the ligature, as 
the parenchymatous, the styptic effects of cold water are very suc- 
cessful. Attempts have even been made to substitute it for the 
ligature after amputation, but improperly, for besides there being no 
valid objection to the use of the ligature, the patient may be 
exhausted by its uncertainty, and too much time be lost, thus delay- 
ing the purpose of the operation. In epistaxis, as well as in bleeding 
from the fauces, rectum, and uterus, cold water is used with the 
happiest results. 

3. In certain chronic and indolent ulcers, as those occurring on 
the lower limbs, the stimulating effect of cold water may be taken 
advantage of to excite healthy granulations, and predispose to form 
cicatrization. 

4. As a means of strengthening the organic fibre, giving tone to 
enfeebled parts, and rendering them less amenable to catarrhal, 
rheumatic, scrofulous, and other inflammatory affections. Thus the 
diurnal washing or shoAvering of particular parts of the body is often 
an excellent prophylactic. A daily cold pediluvium is known to 
diminish the liability to contract catarrh. According to Percy, the 
cold douche may prevent or even cure spontaneous luxations, and 
remove incomplete (extra-capsular) anchylosis. Hippocrates long 
ago advised them in non-ulcerated scrofulous joints, and in the tophi 
of gout and rheumatism ; and advantage is said also to have been 
derived from their use in cases of deformed callus, rickets, etc. 

Continuous Application of Cold Water. — When cold water is 
applied continuously to a part, the reaction which follows its tem- 
porary contact will also take place; its effects, however, being 
suspended or prevented by the continued renewal of cold. The 



WATER — ITS TOPICAL USES IN SURGERY. 9 

temperature of the part remains diminished, the transient reactive 
pain passes off, the redness and tumefaction of the skin disappear. 
The vitality of the part is depressed, and its irritability is moderated. 

If the contact be maintained for a long time, the blood, which is 
constantly driven from the contracted and diminished capillaries, is 
compelled to take another direction. This tendency may be in- 
creased, both by diminishing the mass of blood, and by counter- 
irritation at a distant point. Thus we may moderate or prevent an 
inflammation, or sometimes cause it to abort when already esta- 
blished. In other cases, we can drive the blood from an engorged 
organ, or inversely to a point where its presence is desirable. 

As the continuous application of cold deprives a part of its caloric, 
it acts like an antiseptic, in preventing chemical decomposition and 
putrefaction, which cannot occur without a certain degree of caloric. 

From what we have said of the modus operandi of cold water con- 
tinuously applied, it should prove especially salutary in the treatment 
of the inflammatory process. And since inflammation in its various 
stages is itself the great and frequent condition or complication, 
which the surgeon is called upon to combat, and it is in its treatment 
that the benefits of refrigerants have been most lauded, whilst the 
opposers have here raised their most serious objections, we shall be 
excused on account of its importance for dwelling somewhat on this 
head. 

The means employed for mitigating or abolishing inflammation 
have been classed by McCartney, in his admirable work on the sub- 
ject, under seven heads : — 

1. Remedies which diminish the force of the heart, and give the 
disposition, generally, to the small arteries, to go into the contracted 
state. 

Along with nauseants and general and local abstraction of blood, 
refrigerants certainly diminish the size of the small vessels, and 
consequently the force of the heart also, so far at least as this is 
concerned in impelling the blood through the constricted capillaries 
of a part. Cold water unquestionably fulfils this indication. 

2. Means that effect a diminished size of the arteries, or reduce 
the sensibility in the inflamed part. 

Cold applications do both ; and the more superficial the vessels 
the greater the effects, as in violent sprains of joints. 

3. Lotions or fluids which exert sedative and astringent power. 
Here, too, cold water, even by itself, and unmedicated, completely 

answers the purpose. 



10 WATER — ITS TOPICAL USES IN SURGERY. 

The remaining four heads will find their appropriate place here- 
after, when we come to speak of water of a higher temperature than 
we are now considering, and we shall show how, by lowering or in- 
creasing its caloric, a most important element in the management of 
external lesions, it perfectly answers all the requisitions for the 
treatment of inflammation, so clearly laid down by the above-cited 
author. 

It is in traumatic inflammation, of the true sthenic type, accom- 
panied by much pain, redness, heat, and swelling, such as occur in 
wounds, contusions, fractures, etc., that cold water is especially ser- 
viceable. But from the view which we take of its therapeutical 
action, it follows that the water should be applied cold as long only 
as there is hope that the inflammation will terminate by resolution. 
If it tend by its nature to suppuration, or if suppuration be already 
established (and this may sometimes be desirable), cold applications 
are no longer proper, for they would retard unavoidable suppuration. 
Here the water should be brought to the proper relaxing tem- 
perature. 

We are of opinion that the effects of refrigerants do not extend 
very deeply, and that, therefore, the inflammation should not be very 
profoundly situated to be favourably modified by their use. Seated, 
for example, towards the axis of the thigh or trunk, less advantage 
would be gained from their employment than when its site is in 
more superficial parts. Indeed, some care is requisite in these cases, 
as the cold may mask the inflammatory symptoms and suppuration, 
which it may be important early to detect. 

Different opinions have been entertained concerning the mode of the 
therapeutical action of cold water in inflammations. Thus, the mere 
reduction of caloric, the effect on the nervous extremities, the absorp- 
tion of the water, the diminution of the quantum of blood in the 
part, the uniformity of its temperature maintaining a new action, 
the development of electrical phenomena, have each found sup- 
porters. Without denying the participation of any, we incline to 
think that the diminution of the quantity of blood, and the abstrac- 
tion of caloric, act the most prominent and important part. These 
at least are sensible and appreciable effects, and we should adopt 
them in preference to mere speculation and hypothesis. Absorption, 
it is true, does go on during the continuous application of cold, as is 
easily proved by the experiment of Percy, who plunged a new-born 
puppy into a black-coloured liquid, the urine being thereby rendered 
black. So also turpentine, when applied externally, imparts to the 



WATER — ITS TOPICAL USES IN SURGERY. 11 

urinary secretion its peculiar odour ; and morphine, as well as tartar 
emetic, applied in solution to the surface, will produce on a patient 
their characteristic effects of stupor and nausea. 

Cold applied to an inflamed part is, in one sense, a kind of band- 
age. But over the bandage, cold possesses this advantage, that 
while it compresses (constricts) it also largely depletes the part by 
its abstraction of caloric. The two, by means of a wetted roller, are 
often advantageously combined. 

Certain experiments, made several years ago by my colleague, 
Prof. M. L. Linton, satisfactorily show that, when a bandage is ap- 
plied to several or all of the extremities at the same time, the pulse 
becomes fuller and slower. He has hence deduced some most useful 
and important practical hints. In exhausting and threatening dis- 
charges of the secretions or of blood, the vital fluid may be as it were 
dammed up, in order to sustain the functions of the " tripod of life," 
the heart, the brain, and the lungs. It is well known that the ampu- 
tation of a, leg causes plethora, and many other facts find their 
explanation by this view. Although of far less avail in these par- 
ticular cases, yet similar effects are produced by cold water when 
applied to one or more of the extremities. 

We have selected a number of healthy individuals, whose pulse was 
accurately noted both before and during immersion in water at dif- 
ferent low and ascertained temperatures, and have found the results 
to accord quite accurately with those obtained by Dr. Linton with the 
bandage. On the other hand, by applying ligatures to the limbs, so 
as to detain the blood from the trunk, the pulse became feebler and 
quicker. The student upon whom he made some of his experiments 
said that the bandages caused a feeling of fulness about the head; 
apart from which he observed no other notable change in his sensa- 
tions. A somewhat analogous fact has been communicated to me 
by a reliable medical friend. A man engaged in removing the 
wreck of a sunken steamboat remained for a considerable time with 
his body immersed up to the chin in the cold water of the Mississippi 
River : for some days afterwards, he was the subject of raving 
mania, and continued for some time to evince symptoms of cerebral 
congestion; for the treatment of which affection he had fallen under 
the care of my friend, who, by applying cold to the head, and warm 
water to the extremities, succeeded in completely relieving him. 

If, according to the doctrine of Berard and Barthes, we admit that 
inflammation consists of several elements, and we attack one of these 
before inflammation is established, we may succeed in preventing its 



12 WATER — ITS TOPICAL USES IN SURGERY. 

development. When inflammation already exists, our success in its 
treatment will depend on the relative value of the one or more ele- 
ments which we aim to subdue. Thus opium in large doses, by calm- 
ing pain, often prevents the phlogosis : thus leeches act by drawing 
off the redundant blood. So, too, cold applications, in whatever manner 
continuously used, combat the burning heat and afflux of blood, both 
before and after their appearance. In certain instances cold increases 
the pain, and warm water is required. But this appears evidently 
to be the case when the injury is deep-seated — the cold being super- 
ficial in its effects, increases the congestion towards the axis of the 
part, whereas warm applications, by attracting the blood towards the 
surface, relieve the central congestion. 

In inflammations which are regarded as specific, such as syphilis, 
erysipelas, scrofula, and rheumatism, cold applications should be used 
with greater caution. Our predecessors, however, often employed 
cold effusions both in smallpox and scarlatina, as well as in other 
eruptive fevers, and we see at the present day, the hydriatic treat- 
ment often successful in rheumatism. The reason of an objection to 
cold in these cases is the belief in the existence of a materies morbi, 
which must be eliminated, and which, if repelled from one part, is 
driven to another. In primary syphilis after destruction of the virus, 
water-dressing is highly appropriate and beneficial. In erysipelas, 
we fear the repelling effect of cold, which often produces a metastasis 
to the brain or elsewhere. 

It is important here to observe that age, sex, sensibility, the nature, 
seat, extent, and severity of the disease, the season as well as the 
period of its first application, are all so many circumstances to be 
regarded by the surgeon in his selection of the manner, quantity, 
duration, and temperature of the water to be employed. 

We may proceed to indicate the cases in which the continuous use 
of cold water is advantageous : 1. As a local anaesthetic. From the 
effects which we have described as following the application of water 
of a low temperature, we should, a priori, infer its use in obtunding 
sensibility. We produce a frost-bite of the first degree, when the 
part is said to be "dead." Benefit in this way can only be obtained 
in parts of no great thickness, as the phalanges of the fingers and 
toes, amputations of which have been thus performed, without the 
patient experiencing the least pain. General anaesthesia by the usual 
means of ether or chloroform inhalation will for such purposes, on 
account of a more rapid indication of the desired effect, be perhaps 
preferred: still, cases contraindicating the exhibition of these very 



WATER — ITS TOPICAL USES IN SURGERY. 13 

exceptionally dangerous agents may occur, when for the removal of 
fingers or toes or the ablation of certain tumours, as we have ourselves 
practised, it may be desirable to resort to other means, or to the local 
anaesthetic power of cold. Here, as in other instances, to prevent 
undue reaction, the cold applications of a gradually more elevated 
temperature should be continued as the after treatment. Do not 
ether and chloroform produce local anaesthesia by their evaporations 
inducing cold? Certain it is, we think, that their major action may 
in this way be explained, as their local and general effects seem so 
widely to differ. 

2. In inflammation of particular parts, as (a), in inflammation of 
the brain, especially when induced traumatically. Notwithstanding 
the fear once felt in the use of cold applications to the head, they 
are now, next to bloodletting, generally acknowledged to be one of 
the most powerful remedies in the treatment of such affections. 

(5.) In ophthalmia, attended with ocular pain and cephalic con- 
gestion. Some of the German surgeons are fond of cold applications 
in all purulent ophthalmia, as they think that they prevent the dis- 
charge, and mitigate the violence of the disease. Here, too, its place 
is next to bloodletting. In the ophthalmia neonatorum, cold water 
has been found very serviceable, and excellent success has also at- 
tended its employment in scrofulous photophobia. 

In simple catarrhal ophthalmia, cold applications should not be too 
loner continued. Their good effects are most marked in the earlier 
stages, when, failing, their continuance is likely to induce a rheumatic 
complication. Poppy and other anodyne fomentations are then pre- 
ferable. 

(c.) In traumatic inflammation of the thoracic and abdominal cavi- 
ties, as contusions, wounds, etc., attended by extravasation of blood. 
Many surgeons who employ cold applications in affections of the 
limbs fear their use about the trunk, on account of the proximity of 
serous surfaces, which they allege take on consequent inflammation. 
Marshall Hall strongly recommends them even in ordinary hemopty- 
sis, and they have been and are still used in metro-peritonitis with 
decided advantage.* Our own experience is decidedly favourable to 
them in bleeding, and penetrating wounds of both cavities of the 
trunk, and we have not noticed the production of this dreaded pleurisy 

* But in these cases there is danger, for, as it is difficult for the cold to act except 
at the periphery, it may cause deep-seated congestion. Hence, if water be applied at 
all, it should be in an uninterrupted manner, and at a very low temperature, so as to 
diminish the circulation of both the superficial and central vessels. 



14 WATER — ITS TOPICAL USES IN SURGERY. 

or peritonitis to be attributable to their action. Is there not also a 
serous membrane of the brain ? but we are not on this account deterred 
from their use in traumatic lesions of the head. The osseous envelop 
is not a sufficient explanation of the difference in the two cases. 

(d.) In orchitis, cold applications act most beneficially, so long as 
the true sthenic character prevails. According to Rusk, their use 
should not be too long continued in the inflammation of glandular 
organs, because of the indurations which are likely to follow. This 
surgeon is very partial to the use of cold water in almost all external 
diseases, but for the reason assigned does not admit its employment 
in orchitis even of a traumatic origin. He prefers in such cases warm 
sugar of lead fomentations. This induration, with enlargement, almost 
always follows inflammation of the testicle as an immediate conse- 
quence, under every treatment, and I am not aware that it more fre- 
quently follows the use of refrigerants than other remedies. In the 
earlier active stages of orchitis, their use will, as in other inflam- 
mations, be found, on trial, consonant to the general rule. 

In inflammatory enlargements of the superficial lymphatic glands 
of the groin, along with rest and a compressive bandage, we have 
found cold applications very useful in effecting a return to their nor- 
mal size. There are buboes which will suppurate in spite of all and 
every treatment. In such, the specific for example, where suppura- 
tion is by many regarded as an elimination of the poison, we with- 
hold the use of refrigerants. 

(e.) In inflammation of mucous surfaces, as gonorrhoea, leucorrhoea, 
chronic cystitis, etc., the applications of cold water, either by fomenta- 
tions, irrigation, or injection (in case of the bladder, by means of a 
double catheter), are very useful. The cold imparts tone and strength 
to the relaxed and weakened membrane. In the case of the penis, 
local cold baths are generally to be preferred to injections. Uterine 
injections, however, have of late years met with favourable reception 
in practice. 

(/.) In paraphymosis, the use of cold water is highly serviceable. 
It diminishes inflammation and engorgement, whilst it favours the 
spontaneous reduction of the glans, or proves an efficient aid to the 
manipulatory efforts of the surgeon. The water should be poured 
upon the part from a height for twenty minutes or half an hour before 
attempting the restoration. We have never yet seen a case at all 
acute which has resisted this means and required a resort to the knife. 

Cold applications are applied not only to cure inflammation already 



WATER — ITS TOPICAL USES IN SURGERY. 15 

established, but far oftener to prevent its accession, when likely to 
follow previous injuries. With this view are they especially used 

1. In wounds. The more important the organ injured, the more 
we should strive to ward off inflammation, and consequently the more 
urgently are cold applications indicated. In wounds of the head, of 
the external soft parts, as well as of the cranium and brain, in wounds 
of the chest and abdomen, either penetrating . or not, and, lastly, in 
wounds of the extremities, cold water is a chief remedy, and should 
never, unless for major reasons, be neglected. Its beneficial effects 
are most marked in incised wounds, as amputations and the like, where 
we wish union by the first intention. This important and generally 
desirable process is not in the least hindered, but on the contrary is 
often promoted by the judicious use of refrigerants. In lesions im- 
plicating joints (especially the knee) and peri-tendinous sheaths, no 
other application is superior, although we should not neglect venesec- 
tion, and other means of cure. Did it comport with the plan of the 
present paper, we might cite many striking cases in illustration of the 
great benefit of cold applications. 

In contused, lacerated, and gunshot wounds, they are no less ser- 
viceable. Here it is true that a certain amount of inflammation must 
follow, nor is it intended, as some suppose, altogether to prevent its 
occurrence. We aim simply to moderate and restrain, not to prevent 
or absolutely control. In the first period of gunshot wounds — that 
of shock — cold applications ought, for obvious reasons, to be withheld. 
As this state passes off, they should, however, be sedulously made. 
While, on the one hand, there is but little doubt that in many a grave 
gunshot, or other injury, were the treatment by continuous irriga- 
tion or immersion in cold water, amputation might often be pre- 
vented, and thus both life and limb saved ; on the other, in those com- 
minuted fractures, with division of large bloodvessels and nerves, and 
other serious disorder, we should not indulge the vain hope of saving 
by water or any other treatment, that which it would be both safer 
and more useful to remove. 

As to the length of time required for applying cold water, it will 
depend evidently on the circumstances of the case ; a few days being 
sometimes sufficient, while in others a month or more is necessary. 
Instances are given in which the applications have been continued 
for three months. It is important to remember that, when from any 
cause it may be deemed advisable to discontinue the application, it 
should not be done suddenly, but gradually, and by the substitution 
of water of a more and more elevated temperature. By this means 



16 WATER — ITS TOPICAL USES IN SURGERY. 

the rapid and undue reaction will be prevented, and a more formida- 
ble inflammation averted. 

With respect to the danger of mortification from the continuous 
application of cold, it is by no means clear that the contusion itself 
was not the chief cause of the mortification in cases where this has 
occurred. Certain it is that snow and ice would more likely pre- 
dispose to this untoward accident, which the judicious surgeon can 
generally foresee and prevent. Berard has twice seen, under these 
circumstances, the mortification of the great toe. Whenever the 
connections of the contused part are such as seriously to interfere 
with its circulation, gangrene is to be apprehended, and cold appli- 
cations are to be most warily used. So, too, in severe fractures, 
accompanied by paralysis ; the vitality of the part being lowered, 
the danger of mortification by continuous cold is enhanced. 

Another objection to continued irrigation has been made by M. 
Piorry. It is, he says, a kind of injection, which dissolves the pus, 
introduces it into the open vessels, and thus causes pyaemia. The 
removal by such means of the pus and septic detritus of a part 
was, it would seem, a means rather of preventing than of inducing 
systemic infection. Besides, under the use of cold water, the quan- 
tity of the discharge is diminished, and there is consequently less 
danger of absorption. 

2, In concussion, particularly of important organs, as the brain, 
lungs, and abdominal viscera. Here of themselves cold applications 
are often sufficient to prevent the development of inflammation. It 
is important to recall the fact that, in all cases of severe shock, the 
system should be permitted to recover either naturally or by restor- 
atives, before resort to irrigation or immersion. 

3. In bruise, or contusions of soft as well as of hard parts ; in 
fractures, luxations, and sprains, cold applications are used according 
to the same rules. In sprains, momentary luxations self-reduced, 
conjoined with rest and position, no remedy is equal to them. In 
the swelling and pain which so soon follow on fractures and disloca- 
tions, cold water, by abating both symptoms, is an admirable aid in 
enabling us to examine satisfactorily in order to an exact diagnosis. 
It is equally serviceable in their after treatment. Dupuytren sup- 
posed that cold, whether by water or the atmosphere, retarded and 
occasionally prevented the formation of callus. This can be true 
only when the fractured bone is- near the surface, and when the cold 
is applied to such a degree as to diminish that vascularity of the 
part necessary to the formation of callus. 



WATER — ITS TOPICAL USES IN SURGERY. 17 

4. In incarcerated and strangulated hernia, cold water not only 
prevents the expected inflammation, hut also greatly assists the taxis 
by its contractile effects. It is when the protruded bowel is greatly 
distended by flatus that its beneficial influence is most marked. 
Freezing of the parts in such cases is said to have occasionally 
occurred, an event which moderate attention might easily forestall. 

In prolapsus of the rectum and of the vagina, as also in hemor- 
rhoids, cold water often proves salutary in facilitating the reduction 
of the displaced parts, on the one hand, while, on the other, it pre- 
vents the inflammation which might follow. 

5. For the cure of aneurism and varices. Combined with com- 
pressive bandages, cold water has been used with success, especially 
if the case be recent. It has generally been restricted, except as an 
adjuvant to compression, to internal aneurisms, as of the aorta, etc. ; 
the external being amenable to more certain means of cure. The 
examples of success, according to the method of Valsalva and 
Albertini, are in part to be attributed to the continued application of 
cold. Ice has cured aneurisms; but the best mode of applying cold 
is to envelop the whole limb, including the aneurism, with a roller, 
which should be kept constantly wet with water at a low temperature. 
In cases of internal aneurism, where a cure is not effected, the cold 
serves at least to delay the fatal termination. 

6. In all degrees of burn, cold applications, although objected 
to by many surgeons, have enjoyed great reputation from the most 
ancient to the present time. Pain is at once relieved. The applica- 
tion should, however, be continued, as a suspension would be followed 
by increased inflammation and pain, more agonizing than if cold 
had never been used. In very extensive burns, however, cold water 
is of doubtful utility, on account of its sedative effects on the already 
depressed system. 

7. In commencing bed-sores, cold applications are usually very 
serviceable. 

After the operation for cataract, the constant application of com- 
presses saturated with cold water has a marked effect in preventing 
the development of inflammation. 

II. Ice Water of 32°. — This, as well as snow, and ice, and water, 
of the same temperature, produces an action similar to that already 
noticed, Avith the difference that its effects are more powerful ; 
and it is therefore especially applicable in cases requiring a very 
active treatment. It is important to observe that there is a great 
2 



18 WATER — ITS TOPICAL USES IN SURGERY. 

difference between the effects of water at 32° and those of ice or snow 
at the same temperature, from the fact that either of the latter, in 
passing to the liquid state, renders latent a quantity of caloric equal 
to that which is required to raise the temperature of an equal weight 
of water from 32° to 172°. Gangrene is much oftener the result of 
the inconsiderate employment of ice or snow, than of water, how 
cold soever it may be. There is only the exception of frost-bite, in 
which frictions of snow should precede the use of water of a gradu- 
ally increased temperature, through fear of gangrene. 

M. Baudens, as before observed, is the great partisan of the use 
of ice in surgery. It is, he says, theoretically speaking, difficult to 
understand how a limb may be encased in ice for eight, fifteen days, 
and even a month, without danger, when one may so easily convince 
himself that, by holding a piece of ice between the fingers for a 
minute only, it suffices, so to speak, to freeze them, and cause severe 
pain, with insupportable constriction. In this case, the ice acts on 
healthy tissues, whilst it should be employed only on tissues trauma- 
tically injured. In one case, the ice subtracts the normal caloric ; in 
the other, it withdraws that which is pathological. The distinction is 
important, and should never be lost sight of. This great abstraction 
of pathological caloric is what M. Baudens aptly calls a local bleed- 
ing, not of blood 'but of caloric. In his essay on this subject, read 
before the National Academy of Medicine, he says that it is incredible, 
to those who have not witnessed the fact, that the patient who has 
been relieved by this powerful discharge of morbid caloric, which 
would quickly freeze a limb in its normal conditions, declares the 
limb to be still hotter than the other. By the touch, it is easy to 
convince one's self that the patient is right : that, if the external 
tegumentary layer be cold, there exists deeply an intense focus of 
pathological heat. From the principles laid down, this is all clear 
enough, and is by no means strange. But it may be asked by what 
means did M. Baudens assure himself of it by the touch. We can 
conceive of his touch recognizing the superficial coldness ; but it is 
more difficult to understand how it could at the same time recognize 
the deep-seated heat. 

Ice, ice-water, snow, and all frigorific mixtures, may be used in 
traumatic inflammation of the head and joints, in violent contusions 
of these parts, in severe ophthalmia, and in a number of other cases 
whose indications admit of their use. Ice is best applied by being 
folded in a towel, put into a bladder, or, if to the spine, in the large 
intestine of an animal. 



WATER — ITS TOPICAL USES IN SURGERY. 19 

In certain idiosyncrasies, the use of ice is contraindicated, from its 
producing an erysipelatous inflammation. This may be owing partly 
to a tender skin, and partly to the existence of inveterate rheuma- 
tism. With Velpeau and Guthrie, we are of opinion that ice cannot, 
for obvious reasons, become of general use in hospital or military 
practice ; but we should not on this account forego its employment 
when indicated, and easily accessible. 

Recently, M. Fleury has instituted some skilful experiments with 
cold douches in the treatment of various diseases, particularly chronic 
diseases of joints, chronic engorgement of the uterus, and tumours 
of different kinds, with the view of causing their reduction and ab- 
sorption. Of the value of cold water in the two first-named affections 
we have already spoken : it is on the last that we would make a few 
remarks. The advantageous results obtained by M. Fleury establish 
beyond a doubt that cold douches constitute, by the excitation which 
they produce in the tissues upon which they act, one of the most 
powerful resolutive agents with which we are acquainted. Dr. Sloan 
has tried cold douches in three cases, one of cystic tumour, one of 
goitre, and one of scirrhous breast, and with such success that they 
should suffice to fix the attention of the profession upon this new 
resource of our art. Each douche made daily, occupied from one 
to five minutes. The treatment in the Cystic tumour was continued 
for three months, at the end of which time the tumour had diminished 
one-fourth its size. The goitre lost five-sixths of its volume, and the 
scirrhous breast became stationary, the skin resuming its normal ap- 
pearance. 

We can scarcely hope that cold douches or anything else will super- 
sede the general treatment of tumours by extirpation ; but in those 
capable of absorption, as the sarcomatous and tubercular, the douches 
may be attended with excellent results. If in the malignant and the 
non-absorbable growths, as well as in those cases where an operation 
may be deemed unwarrantable, they delay increase of bulk, a good 
is surely obtained. We hope this subject will receive the attention 
it merits, and that facts sufficiently numerous to establish some gene- 
ral conclusions will be speedily collected. 

III. Tepid Water, 75° to 95° Fahr. — It is of this temperature 
that water is most commonly used for the purpose of cleansing wounds 
and ulcers, and for softening adherent dressings hardened by the. se- 
cretions of the part. In wounds and ulcers occurring in irritable 
constitutions, the local lesions partaking of the same character, and 



20 WATER — ITS TOPICAL USES IN SURGERY. 

in persons and seasons contraindicating the use of cold, the tepid 
water dressing is both comfortable and beneficial. Where ulcers 
present a thin, ichorous discharge, tepid water improves the secre- 
tion, producing laudable pus and healthy granulations, and thus 
favours the desired cicatrization. Kern, of Vienna, is extravagant 
in his praises of tepid water, as a general dressing in all wounds and 
ulcers of either a simple or specific character. In ulcers of the skin, 
and particularly those indolent ones with indurated margins which 
occur on the lower extremities, he thinks it superior to every other 
treatment. Its too long-continued use, however, in ulcers, rather 
delays than favours the healing process, which often requires a treat- 
ment precisely contrary in its effects to those produced by tepid water. 
Tepid water is generally and preferably employed also by M. Amus- 
sat, as set forth in the thesis of his son before alluded to. He thinks 
it possessed of all the advantages, while it is at the same time free 
from the objections urged against cold water, and should therefore 
be generally preferred. The rule which many ancient, as well as 
modern surgeons, follow in the use of water is to have it of a tempera- 
ture agreeable to the sensations of the patient ; and in many cases it 
may yet be considered as the best guide. 

IV. Warm Water, 95° to 125° Falir. — Warm water produces 
immediately the same effects which we pointed out as characterizing 
the reaction that follows on the cold applications when made for a 
short time. By its influence the capillaries dilate, give an easier pas- 
sage to the blood-globules, and admit them in a greater number at 
once. A flow of blood indeed is established whose energy is in pro- 
portion to the temperature of the water, and the duration of its con- 
tact. When not exceeding 125°, there is merely an acceleration in 
the circulatory movement ; but beyond, and especially if the applica- 
tion be prolonged, we may have all the degrees of burn, from simple 
rubefaction to the most complete mortification. We take advantage 
of this property of warm water to diminish dangerous congestions, 
by drawing off the blood to other points, where its accumulation is of 
no inconvenience. As cold water serves in part the purpose of a 
bandage, so does warm water that of a monster cup. This is but the 
counterpart of the ligature to the limbs and confirmatory of those 
suggestions of Dr. Linton above referred to— which we have verified 
by experiment. Thus, in cerebral and other dangerous internal con- 
gestions, we bathe the feet in warm water, to divert blood from the 
tender brain or other important organs. By the afflux of blood 



WATER — ITS TOPICAL USES IN SURGERY. -1 

which its application produces, we use it after leech-bites to encou- 
rage bleeding. 

Warm water is essentially relaxing; it penetrates the tissues, dis- 
tends and softens them, favors circulation, without rendering it much 
more active, and is well adapted to all cases where we seek to subdue 
irritation, rigidity, and dryness. Ordinarily it is customary to incor- 
porate it with some soft substances in the form of poultices, the good 
effects of which, it is contended, are owing solely to the warm water 
(heat and moisture) which they contain. The chief objection to warm 
fomentations is the rapidity with which they cool, thus subjecting the 
part to great alternations of temperature. This may be guarded 
against, in a great measure, by a covering of oiled silk; thus pre- 
venting evaporation, after the manner of Liston's poultices, which 
are preferable to farinaceous or other substances. 

Immersion, if the part admit of it, is the best mode of application, 
and a great desideratum is to find out a method by which this may 
be effected, and the limb be at the same time maintained in an ele- 
vated position. 

In inflammation which must terminate in suppuration, warm water, 
however applied, is very successful. It matures abscesses, and by its 
relaxing effects diminishes the pain and tension attendant on tightly 
confined pus, as when situated in dense cellular and fibrous tissues, or 
beneath fasciae and the periosteum. Next to the relieving incision, 
warm water is in such cases the best and most agreeable remedy. 

By some, it is supposed that the power of warm water in causing 
the abortion of inflammation is very considerable ; still, relief cer- 
tainly follows much more rapidly the use of cold. 

Although the general effects of warm water be relaxing, it is true 
that at the moment of contact the vessels diminish in caliber by tonic 
contraction, particularly if the liquid be near ebullition. The sudden 
immersion of the finger in hot water, it is said, is thus an excellent 
means of arresting, in its debut, the development of a whitlow: the 
tonicity of the capillaries is called into play as just stated, and their 
sudden contraction expels the blood which obstructs them. 

The vapor of hot water is of very useful application in a variety 
of cases. The advantage of making a continued, instead of a tempo- 
rary application, and dispensing at the same time with the woollen 
cloths used in common fomentations, which irritate many wounds and 
ulcers, gives to the mode of administering steam, as recommended by 
McCartney, the character of a new remedy. The temperature, which 
is so essential an element in all local remedies, can be varied at will, 



22 WATER — ITS TOPICAL USES IN SURGERY. 

from a degree of heat too great to be borne, down to below the stand- 
ard temperature of the human body. It is probable, indeed, that the 
soothing influence of a common fomentation is owing to the steam 
generated, yet it is not denied that their agreeable effects may be in- 
creased by the addition of aromatic plants. The effects of steam, 
says McCartney, at a high but comfortable temperature, are gently 
stimulant, and at the same time extremely soothing to the feelings of 
the patient. "When the remedy is used, as recommended, by his appa- 
ratus, immediately after the receipt of any of the following accidents, 
viz., lacerated gunshot and punctured wounds, contusions of bones, 
fractures near joints, recent luxations, bruises and sprains of joints, 
and in all wounds accompanied by a peculiar overcoming pain, and a 
shock to the nervous system, it removes all pain and consciousness of 
injury in a very short time. After the pain and the sense of injury 
have passed away, the steam at a low temperature may be continued ; 
or, if found more convenient, water-dressing may be substituted. In 
injuries to joints and bones, the temperature of the steam ought to be 
gradually reduced ; and when there are open joints, compound luxa- 
tion, or compound fracture, we may meet the invasion of inflamma- 
tion (if it should occur) by bleeding, leeches, and cold, according 
to circumstances. At a low temperature, steam reduces the heat and 
vascular dilatation, while it soothes the sensations of inflamed parts. 
Tepid steam is useful in healing ulcers, and those with luxuriant 
granulations, but hot steam is preferable in the indolent class of sores. 
Steam is also singularly beneficial in inflammation of a more active 
character, attended by violent pain and tension, as in phlegmonous 
abscess, promoting very rapidly the thinning process by which the 
tension of the cavity is removed, and the pus brought towards the 
skin. In certain muscular contractions, in rheumatic ophthalmia, in 
abscesses of the mouth or ear, in suppressed hemorrhoidal or cata- 
menial flows, in non-malignant indurations of the mamma, and in the 
suppression of milk, steam is highly serviceable. Such, at least, are 
the views of McCartney. 

It has been contended that, as simple penetrating wounds of the 
great cavities of the body are not dangerous so much in themselves, 
as by the admission of air to surfaces unaccustomed to its presence, 
it were possible, by excluding this agent, to perform many otherwise 
grave operations implicating joints and serous cavities with compara- 
tively little danger. Thus the extraction of loose cartilages in joints, 
and the removal of ovarian and other abdominal tumours, might be 
more safely attempted in an atmosphere of steam, of a temperature 



WATER — ITS TOPICAL USES IN SURGERY. 23 

the same as that of the body. Were the operations performed under 
water at the proper temperature, it is likely that the same wished-for 
results would follow. But these procedures are attended with such 
difficulties and inconvenience, as the coloration of the water, &c, that 
they are never likely to be frequently, if at all, resorted to. 

V. Boiling Water, 212° Fahr. — When water of this elevated tem- 
perature is brought in contact with the skin, it produces in a lower 
degree an erysipelatous, and in a higher a true phlegmonous inflamma- 
tion, followed by suppuration ; or, by diminishing the vitality, it may so 
far injure the structure of the part as to cause its immediate death. 
It belongs, therefore, to the class of rubefacients, though irritating the 
skin more powerfully and being consequently a greater derivative. 
In apoplexy, apparent death, or where instant vesication is required, 
hot water, applied either with compresses or a sponge, is preferable 
to the ordinary rubefacients. According to Rust, hot water is a very 
excellent remedy in fistulous ulcers, in order to produce an active 
inflammation in their walls, which may lead to their agglutination 
and closure. It thus acts in the same way as caustics or the actual 
cautery, whether heated by fire previous to its introduction, or sub- 
sequently, as platinum wire by galvanism, as lately proposed. He 
also uses it in abscesses of the lymphatic glands with the same view. 
His method is to open the abscess at its most depending part by a 
lancet or trocar, evacuate its contents, and inject as much hot water 
as is sufficient to fill the cavity, allowing it to remain for a few 
seconds. Caustic potash or iodine injections are perhaps preferable 
in both cases. 

In morbus coxarius and other destructive affections of joints, hot 
water is far inferior to either issue, seton, or moxa, for it is likely to 
produce ulcerative inflammation, followed by atonic ulcers, which 
usually heal with great difficulty. 

We are now prepared to notice the remaining remedies for inflam- 
mation, and to show how well, by varying its temperature, water fulfils 
every local indication. 

1. Medicines (remedies) that augment or reproduce the natural 
secretions, and thereby abate the circulation, or lessen the effusions 
made into inflamed parts. 

We have just seen how warm water answers these intentions. 

2. Counter-irritations, secretions, or impressions, made in different 
parts from those inflamed. 

Here the vesicant effect of hot water is available. 



24 WATER — ITS TOPICAL USES IN SURGERY. 

3. Means for modifying, in an agreeable manner, the sensations 
of inflamed parts. 

Steam of a comfortable temperature, or even cold water, fully and 
admirably answers this indication. 

4. Causes which produce an easy or satisfied state of feeling, on 
the sentient surfaces, or in the individual. 

Whatever gives ease to an aching part will also tranquillize the 
individual, so that this indication also is met by the application of 
either steam or cold water. Moreover, under the two last heads, the 
application of anodynes, when deemed advisable, is best made when 
dissolved in an aqueous solution, whether warm or cold. 

In conclusion, we would express the conviction that the Association 
has acted wisely in substituting essays on special subjects for the 
multiform reports of former years ; for the mind, concentrated on a 
particular topic, is apt the better to perceive all its relations and 
bearings. 

Whether we have succeeded or not in shedding any additional light 
on the theme assigned us, we at least feel confident that, in its inves- 
tigation, we ourselves have derived both pleasure and advantage.